Surgical
treatment of popliteal artery aneurysm: a 32-year experience
(Portuguese
PDF version)
Paulo
Kauffman1, Pedro Puech-Leão2
1.
Assistant professor, Surgical Department of the Hospital das Clínicas,
School of Medicine of Universidade de São Paulo.
2.
Professor, Surgical Department of the Hospital das Clínicas, School of
Medicine of Universidade de São Paulo. Correspondence:
Paulo Kauffman
Av. Nove de Julho, 3229/709
CEP 01407-000 - São
Paulo - SP
Tel.: +55 11 3887.8887
Fax: +55 11 3051.6447
E-mail: pauloka@attglobal.net
ABSTRACT Objective:
to present our 32-year experience in the surgical treatment of popliteal aneurysm
in 112 patients (106 males and six females). Method:
The age of patients ranged from 39 to 93. Aneurysms were bilateral in 57 cases.
Arterial hypertension was observed in 51% of the cases and abdominal aortic aneurysm
occurred in 28%. Forty extremities (28%) were asymptomatic, five (3.5%) aneurysms
were ruptured, 25 (17.5%) showed compression of venous and neural structures and
72 (51%) had ischemic complications. The treatment consisted of bypass graft exclusion
of the aneurysm in 93 limbs and no arterial repair in two limbs; resection of
the aneurysm sac with interposition graft in 36 extremities and end-to-end anastomosis
in one; lumbar sympathectomy in four, primary amputation in four and endovascular
treatment in two limbs. Results:
In the postoperative period, 13 limbs, which already showed complications on initial
examination, developed gangrene and had to be amputated; all asymptomatic aneurysms
had a good outcome. The blood flow was maintained in three limbs treated with
exclusion; this occurred due to technical failure in one case and because of the
persistence of collateral sources in the other two. Both cases treated with endovascular
surgery showed occlusion of endoprostheses some months afterwards. Conclusions:
We conclude that popliteal aneurysms should be surgically treated as early as
possible after its diagnosis, preferably before ischemic complications occur.
Key words: aneurysm, popliteal artery, treatment.
Palavras-chave:
aneurisma, artéria poplítea, tratamento. J
Vasc Br 2002;1(1):5-14
Although popliteal
aneurysms are clinically infrequent, they are the most common type of peripheral
aneurysms. The natural evolution of these aneurysms shows severe ischemic complications
in 18 to 31% of the limbs, unless they are previously treated with surgery.1,2,3
Atherosclerosis is the most usual cause of popliteal aneurysm. The diagnosis of
this type of aneurysm is only made when arterial dilatation is comprehensive or,
in most cases, when ischemic complications are present in the limb. Before
the introduction of modern vascular repair techniques, two hallmarks in the history
of popliteal aneurysm treatment should be depicted: a) in 1785, Desaut, in France,
and Hunter, in England, carried out superficial femoral artery ligation in the
adductor canal, thus inaugurating the so-called Hunterian ligation of popliteal
aneurysm, which lasted nearly one century. With this technique, 10.5% of the cases
presented gangrene in the extremity; b) in 1888, Matas developed a technique known
as endoaneurysmorrhaphy, only published in 1903, which aimed at preserving collateral
circulation. This method allowed reducing amputation rate to 5.2%.4,5 Lumbar
sympathectomy, before the endoaneurysmorrhaphy proposed by Bird and adopted and
widely diffused by Linton,6 showed good results with
respect to limb loss, since no amputation was required, even though most patients
complained of pain similar to that of intermittent claudication. With
the advent of modern techniques in arterial surgery, popliteal aneurysm is treated
with resection of the aneurysm sac and restoration of arterial continuity by using
the autologous vein or synthetic prosthesis as arterial substitutes. In 1969,
in order to simplify the surgical technique, Edwards7
introduced the exclusion of aneurysms by "tying off" the arteries above
and beneath them, thus allowing for blood flow restoration via a bypass graft.
This technique is preferably used in the classes of Vascular Surgery at the School
of Medicine of Universidade de São Paulo. The
present article presents the results obtained through the surgical treatment of
142 atherosclerotic aneurysms of the popliteal artery within a 32-year period
(1968 - 2000) in the classes of Vascular Surgery, Surgical Department of the School
of Medicine of Universidade de São Paulo and also in private practice.
The initial experience with the first 37 aneurysms was already published previously.4 PATIENTS
AND METHODS One
hundred forty-two aneurysms of 112 patients (106 males and six females), whose
age ranged from 39 to 93 years (Table 1), were surgically treated. On initial
examination, 55 presented with unilateral aneurysm and 57 showed bilateral aneurysm;
six patients who initially had unilateral aneurysm developed popliteal dilatation
on the other limb at a time interval of 3 to 10 years.  Table
1 - Age range of 112 patients with popliteal artery aneurysm
 |
| Age
(years) | n.
of cases | % |
|
| <40 | 1 | 1 |
| 41-50 | 2 | 2 |
| 51-60 | 23 | 21 |
| 61-70 | 48 | 43 |
| 71-80 | 26 | 23 |
| 81-90 | 11 | 9 |
| >90 | 1 | 1 |
| Total | 112 | 100 |
|
As for
associated diseases (Table 2), arterial hypertension predominated in 51% of the
patients. Abdominal aortic aneurysm occurred in 28% of the cases, and association
of aneurysms at other sites was found in 8% of the patients. Signs of atherosclerosis
in other organs (heart and brain) were relatively frequent and diabetes was observed
in 13% of the patients. Table
2 - Associated diseases in 112 patients with popliteal artery aneurysm
|
| Disease | n.
of cases | % |
|
| Arterial
hypertension | 57 | 51 |
| Aortic aneurysm | 31 | 28 |
| Atherosclerotic
heart disease | 28 | 25 |
| Diabetes | 15 | 13 |
| Cerebral
vascular deficiency | 12 | 11 |
| Other aneurysms | 9 | 8 |
|
Clinical
Status In
40 extremities, the presence of aneurysm was detected on physical examination
and was not symptomatic. Most of these patients sought medical care for having
bilateral involvement of the popliteal artery with symptoms on the opposite limb;
72 patients presented with acute arterial insufficiency of the limb, 30 of them
because of distal embolization (Figure 1) and 42 due to aneurysmal thrombosis;
venous compression (edema, cyanosis, collateral circulation) and/or neural compression
(pain, paresthesia, functional insufficiency) was observed in 25 extremities,
two of which revealed an infected aneurysm; aneurysm rupture with sudden expansion
of the pulsating tumor, pain and knee joint restriction occurred in five limbs. Figure
1 - Ischemic areas on toes and foot sole caused
by distal embolization in patients with popliteal artery aneurysm. 
Surgical
Treatment The
anteromedial access route in the upper third of the leg and in the lower third
of the thigh was used for 120 limbs, while the posterior route, in the popliteal
cavity, was employed in 14 extremities. In the remaining eight limbs, the artery
was not accessed. The
different techniques used on the 142 limbs are shown in Table 3. Exclusion was
applied in 67% of the limbs, and consisted of proximal and distal ligation of
the artery and blood flow restoration by means of autologous saphenous vein bypass
graft in 88 extremities and by means of PTFE bypass graft in five limbs; proximal
and distal ligation was used in two limbs and, since it was not possible to restore
blood flow, a lumbar sympathectomy was performed in one case. Table
3 - Surgical techniques employed in the treatment of 142 popliteal artery aneurysms
in 112 patients
|
| Type
of surgical technique | n.
of aneurysms | % |
|
| Exclusion
+ | Autologous
vein graft | 88 | 62.0 |
| PTFE bypass
graft | 5 | 3.5 |
| Lumbar sympathectomy | 1 | 0.6 |
| No arterial
restoration | 1 | 0.6 |
| Resection
+ | Autologous
vein graft | 34 | 24.0 |
| PTFE bypass
graft | 1 | 0.6 |
| Dacron graft | 1 | 0.6 |
| End-to-end
anastomosis | 1 | 0.6 |
| Lumbar
sympathectomy | 4 | 3.0 |
| Primary
amputation | 4 | 3.0 |
| Endovascular
treatment | 2 | 1.5 |
|
A partial
or total resection of the aneurysm sac was carried out in 26% of the limbs; for
the sake of restoring arterial continuity, an autologous vein graft was used in
34 extremities, PTFE and Dacron prosthetic grafts were used on one limb each;
an end-to-end anastomosis was used on one limb. In acute cases of distal embolization
or aneurysmal thrombosis, Fogarty catheter was systematically used to remove blood
clots from distal arteries. Sympathetic
denervation was employed in four cases as an isolated treatment alternative. In
these cases, the aneurysm was obstructed and the limb kept reasonable conditions
of circulatory compensation, showing hypothermia and vasomotor disorders; primary
amputation was performed in other four cases because of irreversibly ischemic
extremity. Endovascular
treatment was used on two limbs, by means of an internal, valveless saphenous
vein graft fixed at the proximal extremity to a stent; this stent graft was passed
retrogradely through the distal popliteal artery, which was surgically disected,
and the distal extremity of the vein was inserted in end-to-end anastomosis into
the popliteal region according to the technique that was previously mentioned.8 RESULTS
Table 4 shows the
results obtained from the surgery as well as the initial clinical status of the
patients. The result was considered to be excellent whenever pulse was palpable
in at least one distal artery (posterial tibial or dorsal artery of foot) after
restoration of trunk circulation; good, when the perfusion condition of the limb
was satisfactory, even though distal artery pulses were not palpable; and poor,
in cases in which there was severe ischemia with limb loss. Table
4 - Results of surgical treatment of 142 popliteal aneurysms in 112 patients according
to the clinical status
|
| Clinical
status | n.
of aneurysms |
Results | | E | G
| P |
|
| Asymptomatic
| 41 | 39 | 2 | 0 |
| Ruptured | 5 | 4 | 1 | 0 |
| Compression
of vein or nerve | 25 | 21 | 3 | 1* |
| Peripheral
Ischemia | | | | |
| Distal embolization | 30 | 17 | 11 | 2 |
| Thrombosis | 41 | 16 | 11 | 14** |
|
*
infected ** two deaths E= excellent G= good P= poor
The results
were favorable in 41 asymptomatic aneurysms, excellent in 39, and good
in two, both of which showed absence of pedal pulse before surgical
intervention.
In
ruptured aneurysms, the result was excellent in four and good in one, in which
only proximal and distal ligation, combined with lumbar sympathectomy, was carried
out. Among
the 25 cases in which venous or neural compression was present, the result was
considered to be excellent in 21, good in three and poor in one limb, in which
the aneurysm was infected. The two patients treated by the endovascular approach
belonged to this group: one male with signs of venous compression and one female
with symptoms of neural compression of the limb. In
30 cases in which distal embolization was present, the result was excellent in
17, good in 11 and poor in two limbs. Less satisfactory results were obtained
from limbs with acute aneurysmal thrombosis: 16 were considered to be excellent,
11 were good and 14 were poor; in the latter, revascularization was not possible,
and severe ischemia and gangrene followed. Prior to surgical correction, fibrinolytic
treatment was applied to one patient with acute aneurysmal thrombosis, with good
results. Two patients died before 30 days had passed after the surgery due to
respiratory complications secondary to limb amputation caused by aneurysmal thrombosis.
Early
complications Table
5 shows early complications observed in the treatment of 142 popliteal artery
aneurysms. The most frequent complication was edema of the ankle and leg in the
surgically treated limb. This type of edema occurred in 33 cases, and was controlled
by compression therapy with elastic stockings. Local infection with partial dehiscence
of the scar occurred in six cases. Three patients who had aneurysmal thrombosis,
severe limb ischemia and who were submitted to revascularization, distal thrombectomy
with Fogarty catheter and fasciotomy with satisfactory results, presented muscle
disorders in the anterolateral region of the leg, which resulted in local fibrosis;
all patients were submitted to physical therapy and had satisfactory restoration
of limb function. One patient with a large aneurysm, treated with exclusion and
venous bypass graft, showed restricted flexion of the knee joint due to the presence
of hard and nonpulsating tumor in the popliteal cavity for approximately four
months. This patient gradually recovered as part of the thrombosed aneurysm sac
was reabsorbed. Table
5 - Early complications observed in 142 limbs with popliteal artery aneurysms
surgically treated
|
| Complications | n.
of limbs |
% | |
| Edema | 33 | 23 |
| Gangrene | 13 | 9 |
| Local infection | 6 | 4 |
| Necrosis
of leg muscles | 3 | 2 |
| Severe venous
thrombosis | 2 | 1.5 |
| Knee flexion
difficulty | 1 | 0.7 |
| Lymphatic
fistula | 1 | 0.7 |
|
Late
complications Among
all the limbs submitted to arterial repair, 13 showed graft obstruction, nine
had circulatory compensation, and four extremities presented severe ischemia and
had to be amputated. The two limbs treated by the endovascular approach presented
an occluded endoprosthesis in three and 11 months, respectively; both showed adequate
circulatory compensation. In
three limbs in which aneurysm was treated by means of exclusion and bypass graft,
the pulsatility of the aneurysm sac persisted. In two of these limbs, proximal
ligation was carried out far from the aneurysm neck, which continued to be fed
by deep femoral artery branches; both were treated via surgery, which consisted
in opening the aneurysm sac, partially resecting it, and tying off the collaterals.
In the remaining case, there was a technical failure in the distal ligation of
the popliteal artery on the initial surgery, which resulted in retrograde filling
of the aneurysm sac (Figure 2); the surgical correction consisted only of the
appropriate ligation of the distal artery to the aneurysm. Figure
2 - Persistent flow in the aneurysm due to inappropriate
ligation of the distal popliteal artery, resulting in retrograde filling of the
aneurysm sac. 
DISCUSSION
The atherosclerotic
aneurysm of the popliteal artery is a disease that affects almost exclusively
men.1,2,9,10,11,12,13
This also occurred in our study population. Also, some studies report its prevalence
among male patients.4,14,15 Most
of these aneurysms affect patients who are over 50 years old, as corroborated
by the present article. However, few authors have operated patients older than
90 years;1,16 among our
patients, the oldest was 93 years old. This patient was submitted to emergency
surgery due to ischemic complications of the limb caused by distal embolization.
The extremity was successfully revascularized, but the patient died three months
afterwards because of cardiac complications. On
the other hand, when patients under 40 are affected, other etiologies, such as
infections, trauma or entrapment of the popliteal artery, should be considered;
Nevertheless, even in these cases, aneurysms can be of atherosclerotic origin,
as observed in our youngest patient and as reported by Gisserot et al.17 Although
some reports point out that bilateral popliteal aneurysm affects older patients
at a higher frequency than those patients with unilateral arterial dilatation,18
this was not observed among our patients and was not observed by other authors
either.2 Arterial
hypertension is the condition most frequently associated with this kind of aneurysm;1,2,19,20
indeed, it is one of the factors that contributes towards the formation and development
of aneurysms.13 The
presence of associated aneurysms at other sites was observed in 35% of our patients,
and abdominal aortic aneurysm prevailed (27%). This percentage is, however, low
if compared to that reported by other authors, who found a rate of 35 to 50%.1,2,12
There are a few reports that show that this association is more common among patients
with bilateral popliteal aneurysm, affecting up to 70% of them.3
This was also detected among our patients: this association occurred in only 20%
of the patients with unilateral aneurysm and in 35% of those with bilateral involvement
of the popliteal artery. These low rates of association in comparison with those
observed in literature can be explained by the fact that only in the last few
years abdominal ultrasonography has been adopted at our service as a routine practice
for patients with popliteal aneurysm. Atherosclerotic
coronary disease was diagnosed in 23% of our patients, which is a low rate if
compared to that found by other authors.9,12,21
This is probably due to insufficiently rigorous cardiac examination of patients
with popliteal aneurysm in the last decades. As ischemic cardiopathy is the major
cause of death in these patients,12 it is advisable
to evaluate them and treat this condition before treating the aneurysm. Diabetes
mellitus occurred in 13% of our patients, a rate that was similar to that observed
by other authors;19,22
in a previous series,4 as well as in the patients
studied by Vieira,23 there was no diabetic patient;
in diabetes mellitus, the obstructive characteristic of atherosclerosis predominates,
which explains the low incidence of arterial dilatation in diabetic patients. The
most common clinical signs that lead the patient to seek medical care are of ischemic
nature. The
fragmentation of parietal thrombi with distal embolization determines a rather
extensive obstruction of the distal arterial bed, thus originating variable clinical
signs. In acute cases, there may be pain and cyanosis in one or more toes, or
in more severe cases, there may be more extensive ischemic signs in the extremity;
in some patients, the emboli can progressively obstruct the arteries of the leg
and foot without clear signs of acute ischemia, determining pain similar to intermittent
claudication. This was the main symptom reported by 23 patients in our study group
and was also the most frequent ischemic sign in a multicenter study of popliteal
aneurysms conducted in the United Kingdom in 1994.11
Although atherosclerotic patients can have chronic occlusion of the tibiofibular
vessels, the level of distal involvement observed in these patients is higher
than expected.24 Asymptomatic progressive microembolization
probably occurs with a higher frequency than the incidence of diagnosed embolization
suggests. The occlusion of distal arteries increases the resistance to runoff,
thus favoring aneurysmal thrombosis. Since the small dilatation of the popliteal
artery can evolve into thrombosis, some cases labeled as acute arterial thrombosis
of the femoropopliteal region are likely to have an acutely obstructed aneurysm.5 The
careful palpation of the popliteal cavity and of the lower and medial third of
the thigh can detect a pulsating and expansible tumor mass, allowing for clinical
diagnosis in several cases. As the popliteal artery is deep, it is hard to make
such diagnosis when the aneurysm has less than 3 cm in diameter, especially in
persons with bulky limbs.25 When dilatation is large,
it can be observed in the popliteal cavity; in one of our patients, the aneurysm
was so large that, when the patient was lying in a supine position, the limb,
which leaned against the examination table, synchronically throbbed with arterial
pulse. In case of thrombosed aneurysm, the hardened tumor mass in the popliteal
fossa is palpable. It is important to distinguish thrombosed aneurysm from nonvascular
tumors, especially Baker's cyst, by using complementary exams such as duplex imaging.26 Ultrasound
scan, either with or without the use of Doppler, is the most frequently used imaging
technique since it provides very accurate information about the aneurysm: extension,
diameter of dilatation and presence of parietal laminar thrombi (Figure 3); when
combined with Doppler, it allows investigating the characteristics of blood flow.
Davis et al. used ultrasonography and found that the normal diameter of the popliteal
artery is on average 9 mm.27 Therefore, an artery
with 1.5 cm in diameter is considered to be aneurysmatic. However, most authors
agree with the proposition made by Szilagyi et al.,28
which only considers the popliteal artery to be aneurysmatic when it has at least
2 cm in diameter. Figure
3 - Ultrasound scan showing popliteal artery
aneurysm with thick layer of parietal laminar thrombi. 
Computed
tomography or angiotomography (Figure 4) can be used as a complementary diagnostic
tool. Some authors regard it as more accurate than ultrasound scan, for it shows
the layer of parietal thrombi with enhanced clarity.24 Figure
4 - Angiotomography showing small aneurysms in the right popliteal artery
and obstruction of the left popliteal artery. 
Arteriography
(Figure 5) is used to determine the extension of the aneurysm and the condition
of the arterial trunks downstream and upstream. This exam allows planning the
surgery more appropriately. However, as arteriography only shows the lumen of
the vessel, it is not enough to show the actual dimension of the aneurysm in some
cases.2,19,23,25,29,30,31 Figure
5 - Arteriography of large popliteal aneurysm,
where it is not possible to identify the thick layer of thrombi that covered the
inner part of the arterial wall. 
Surgery
is always recommended for symptomatic aneurysms; however, this procedure is controversial
in asymptomatic cases. Most authors recommend surgical treatment of aneurysms
that are larger than 2 cm; nevertheless, the presence of mural thrombi detected
by the ultrasound scan or computed tomography is more important than the dimension
of arterial dilatation, since these thrombi cause thromboembolic complications
even in small aneurysms.2,4,25,32,33 The
good results obtained through the surgical treatment of asymptomatic cases in
comparison with the cases of ischemic complications reinforces our conviction
that surgery is the best alternative, since several authors showed high rates
of thromboembolic complications when the conservative treatment was used.10,13
When these complications occurred, especially in the cases of acute aneurysmal
thrombosis, the attempt to restore the blood flow to the limb was not successful
in 36% of the cases, and then amputation was required. The
efficient use of thrombolytic agents in the initial treatment of thromboembolic
complications, as in one of our patients, has led some authors to opt for the
conservative treatment of asymptomatic aneurysms.34
However, one should remember that the use of these agents is not free from complications:
locally, the partial dissolution of a vast amount of thrombi can produce distal
embolization with deterioration of the limb's ischemic condition;35
systemically, thrombolytic agents favor hemorrhage and cerebral vascular accidents,
especially in elderly patients.5 Some
authors advocate the use of conservative treatment of asymptomatic aneurysms by
alleging that elderly patients have less life expectancy than healthy individuals
in the same age group.2,12,34
Nonetheless, the results of the elective surgical treatment have been better than
those of conservative treatment in the first two years after the aneurysm is detected.31
Therefore, conservative treatment should only be considered for patients with
poor health and with quite limited life expectancy.5,31 The
anteromedial access route, also preferred by other authors,2,14,23
allows easier removal of the vena saphena magna from the thigh without having
to change the patient's position on the operating table; the downside of using
this route is that the pes anserinus tendon must be sectioned so that the aneurysm
sac can be resected. The
exclusion of the aneurysm, proposed by Edwards,36
was employed in 67% of surgically treated limbs in our study. The advantages of
this technique are: the aneurysm is not disected, mobilized or resected, consequently,
the risks of injury to the underlying anatomical structures, with excessive bleeding
caused by dissection, distal embolization due to the surgical manipulation of
the aneurysm sac and formation of hematoma in the dead site created by resection
are minimal; in addition, the surgery is simpler and less traumatizing.37
The disadvantage of the exclusion method is that the aneurysm is turned into a
hard tumor due to blood coagulation in its interior, thus hindering normal flexion
of the knee, as occurred with one of our patients. To avoid such complication,
which could arise in case of large aneurysms, some authors recommend that the
aneurysm be partially or totally resected during the surgery.2,19,28 Furthermore,
the exclusion method can cause occasional persistence of blood flow in the aneurysm,
which can keep expanding until it eventually ruptures. The cause of this complication
is the existence of important collaterals arising from the artery or from the
aneurysm itself; this occurs when the arteries are tied off during surgery or
when arterial ligation is far from the aneurysm sac, as occurred in two of our
patients.28,38,39
The persistence of blood flow in the aneurysm can be prevented by good-quality
preoperative arteriography, which will detect the collaterals and tie them off,
whenever possible.37 However, even aneurysms that
are free of blood flow and of pulsatility can continue to grow, causing local
compression.22 Actually, the advantages of the exclusion
method outnumber its disadvantages; therefore, it is still the treatment of choice
of several surgeons for popliteal artery aneurysm.5,37,38 The
endovascular approach has been seldom used. Although the immediate results of
this technique are good, they are not yet convincing in the medium run. Consequently,
the available literature on the use of this method is scarce.40,41,42,43,44,45
In our study population, only two patients with popliteal aneurysm were submitted
to endovascular surgery. Both showed excellent immediate results (Figure 6), but
they had occlusion within some months, even though a saphenous vein graft (material
that best withstands flexion of the knee joint) had been used. Figure
6 - Pre- (on the left) and postoperative (on
the right) arteriography of aneurysm treated through endovascular approach (on
the right). 
Since
these patients tend to present aneurysmal degeneration, it is essential that they
be monitored and followed up in the long run so that we can prevent the development
of aneurysms that were not there at the beginning, as occurred in the popliteal
artery of the other limb in six of our patients. The regular use of ultrasonography
of both the abdomen and of the surgically treated segment is crucial during the
follow-up period, since it can indicate the development of abdominal aortic aneurysm
and also the development of aneurysm in the segments that are adjacent to the
previously treated popliteal artery, as referred by some authors.13,46
Dawson et al. predicted the development of new aneurysms in 6% at the end of the
first year and 49% after 10 years, with a higher incidence among hypertensive
men older than 65 years, who presented with bilateral aneurysmal dilatation of
the popliteal artery on initial examination.13 Although
there may be occasional occlusion of the graft with time, amputation is not required
if the distal arterial bed is in good repair at the time of surgery; this was
observed in nine of our patients. This occlusion is gradual during the follow-up
period and allows for adequate collateral circulation which, in its turn, provides
the limb with adequate blood flow after thrombosis in the surgical repair.46 We
conclude that popliteal aneurysm should be a concern of physicians who treat elderly
patients. It is essential that this disease be early diagnosed and surgically
treated in order to prevent ischemic complications, which could worsen the prognosis
of these patients. REFERENCES
1.
Wychullis AR, Spittel Jr. JA, Wallace RB. Popliteal aneurysms. Surgery 1970;68(6):942-52.
2.
Vermillion BD, Kimmins SA, Pace WG, Evans WE . A review of one hundred forty-seven
popliteal aneurysms with long term follow-up. Surgery 1981;90(6):1009-14. 3.
Whitehouse Jr. WM, Wakefield TW, Graham LM, et al. Limb-threatening potential
of arteriosclerotic popliteal artery aneurysms. Surgery 1983;93(5):694-9. 4.
Kauffman P, Cinelli Jr. M, Langer B, et al. Aneurismas arterioscleróticos
da artéria poplítea. Rev Paul Med 1984;102:145-50. 5.
Kauffman P. Aneurismas nos membros inferiores. In: Puech-Leão P & Kauffman
P. Aneurismas arteriais. São Paulo: Fundo Editorial Byk; 1998. p.204-17. 6.
Linton RR. The arteriosclerotic popliteal aneurysms. Surgery 1949;26:41-58. 7.
Edwards WS. Exclusion and saphenous vein bypass of popliteal aneurysms. Surg Gynecol
Obstet 1969;128:829-30. 8.
Puech-Leão P, Kauffman P, Wolosker N, Aanacleto AM. Endovascular grafting
of a popliteal aneurysm using the saphenous vein. J Endovasc Surg 1998;5:64-70. 9.
Anton GE, Hertzer NR, Beven EG, O'Hara PJ; Krajewski LP. Surgical management of
popliteal aneurysms: trends in presentation, treatment and results from 1952 -
1984. J Vasc Surg 1986;3(1):125-34. 10.
Roggo A, Brunner U, Ottinger LW, Largiader F. The continuing challenge of aneurysms
of the popliteal artery. Surg Gynecol Obstet 1993;177(6):565-72. 11.
Varga ZA, Locke-Edmunds JC, Baird RN. A multicenter study of popliteal aneurysms.
J Vasc Surg 1994;20(2):171-7. 12.
Lowell RC, Glowiczki P, Hallet Jr. JW, et al. Popliteal artery aneurysms: the
risk of nonoperative management. Ann Vasc Surg 1994;8(1):14-23. 13.
Dawson I; van Bockel JH; Brand R; Terpstra JL. Popliteal artery aneurysms. Long
term follow-up of aneurysmal disease and results of surgical treatment. J Vasc
Surg 1991;13(3):398-407. 14.
Evans WE, Conley JE, Bernhard V. Popliteal aneurysms. Surgery 1971;70:762-767. 15.
Guvendik L, Bloor K, Charlesworth D. Popliteal aneurysm: sinister harbinger of
sudden catastrophe. Br J Surg 1980;67:294-6. 16.
Hands LJ, Collin J. Infra-inguinal aneurysms: outcome for patient and limb. Br
J Surg 1991;78:996-8. 17.
Gisserot O, Cellarier G, et al. Aneuvrisme poplite juvenile. J Mal Vasc 1999;24:306-8. 18.
Evans WE, Turnipseed WD. Popliteal aneurysms. Vasc Surg 1976;10:86-91. 19.
Crichlow RW, Roberts B. Treatment of popliteal aneurysms by restoration of continuity:
review of 48 cases. Ann Surg 1966;163:417-426. 20.
Hardy JD, Tompkins WC, Hatten LE, Chavez CM. Aneurysms of the popliteal artery.
Surg Ginecol Obstet 1975;140:4012-404. 21.
Schellack J, Smith RB III, Perdue GD. Nonoperative management of selected popliteal
aneurysms. Arch Surg 1987;122:372-5. 22.
Shortell CK, Deweese JA, Ouriel K, Green RM. Popliteal artery aneurysms: a 25-year
surgical experience. J Vasc Surg 1991;14:771-9. 23.
Vieira GN. Aneurismas arteroscleróticos da artéria poplítea.
Arq Cat Med 1980;9:57-70. 24.
Lilly MP, Flinn WR, McCarty WJ, Courtney DF, Yao JS, Bergan JJ. The effect of
distal arterial anatomy on the success of popliteal aneurysm repair. J Vasc Surg
1988;7(5):653-60. 25.
Inahara T, Toledo AC. Complications and treatment of popliteal aneurysms. Surgery
1978;84:775-783 . 26.
Molnar L. Ultra-sonografia e eco-Doppler. In: Puech-Leão P, Kauffman P.
Aneurismas arteriais. São Paulo: Fundo Editorial Byk; 1998. p.21-31. 27.
Davis RP, Neiman HL, Yao JST, Bergan JJ. Ultrasound scan in diagnosis of peripheral
aneurysms. Arch Surg 1977;112:55-8. 28.
Szilagyi DE, Schwartz RL, Reddy DJ. Popliteal arterial aneurysms. Arch Surg 1981;116:724-8. 29.
Howell JF, Crawford ES, Morris Jr GC Garrett HE, De Bakey ME. Surgical treatment
of peripheral arteriosclerotic aneurysm. Surg Clin North Am 1966;46(4):979-89. 30.
Turnipseed WD; Acher CW; Detmer DE, et al. Digital subtraction angiography and
B-mode ultrasonography for abdominal and peripheral aneurysms. Surgery 1982;92(4):619-26. 31.
Graham LM. Femoral and popliteal aneurysms. In: Rutherford RB. Vascular Surgery.
5ª ed. Philadelphia: Saunders; 2000. p.1345-56. 32.
Bouhoutsos J, Martin P. Popliteal aneurysms: a review of 116 cases. Br J Surg
1974;61:469-75. 33.
Locati P, Socrate AM, Constantini E, Campanati B. Popliteal aneurysms: current
management and outcome. Minerva Cardioangiol 1999;47:145-55. 34.
Bowyer RC, Cawthorn SJ, Walker WJ, Giddings AE. Conservative management of asymptomatic
popliteal aneurysm. Br J Surg 1990;7:1132-5. 35.
Galland RB, Earnshaw JJ, Baird RN, et al. Acute limb deterioration during intra-arterial
thrombolysis. Br J Surg 1993;80(9):1118-20. 36.
Edwards WS. Exclusion and saphenous vein bypass of popliteal aneurysms. Surg Gynecol
Obstet 1969;128:829-30. 37.
Cinelli Jr M, Kauffman P, Sacilotto R, et al. Complicação rara da
cirurgia do aneurisma da artéria poplítea: relato de caso e considerações
sobre a técnica cirúrgica. Rev Assoc Med Bras 1991;37:157-9. 38.
Flynn JB, Nicholas GG, Mckinnon WM. An unusual complication of bypassed popliteal
aneurysm. Arch Surg 1983;118:111-3. 39.
Battey PM, Skardasis GM, Mckinnon WM. Ruptured of a previously bypassed popliteal
aneurysm: a case report. J Vasc Surg 1987;5:874-5. 40.
Marin ML, Veith FJ, Panetta TF, et al. Transfemoral endoluminal stented graft
repair of a popliteal artery aneurysm. J Vasc Surg 1994;19(4):754-7. 41.
Krajcer Z, Diethrich EB. Successful endoluminal repair of arterial aneurysms by
Wallstent prosthesis and PTFE graft: preliminary results with a new technique.
J Endovasc Surg 1997;4:80-7. 42.
Kudelko PE , Alfaro-Franco C, Diethrich EB, Krajcer Z. Successful endoluminal
repair of a popliteal artery aneurysm using the wallgraft endoprosthesis. J Endovasc
Surg 1998;5:373-7. 43.
Burger T, Meyer F, Tautenhahn J, Halloul Z; Fahlke J. Initial experiences with
percutaneous endovascular repair of popliteal artery lesions using a new PTFE
stent-graft. J Endovasc Surg 1998;5(4):365-72. 44.
van Sambeek MR, Gussenhoven EJ, van der Lugt A, Honkoop J, du Bois NA, van Urk
H. Endovascular stent-grafts for aneurysms of the femoral and popliteal arteries.
Ann Vasc Surg 1999;13(3):247-53. 45.
Meissner O, Preteñir R, Kellner W, et al. Endoluminal repair of peripheral
arterial aneurysms: 4 - year experience with the cragg endopro system I. J Vasc
Interv Radiol 2000;11(5):593-600. 46.
Towne JB; Thompson JE; Patman DD; Persson AV. Progression of popliteal aneurysmal
disease following popliteal aneurysm resection with graft: a twenty year experience.
Surgery 1976;80(4):426-32. | 
